Sympathetic block: Thoracic and lumbar

Techniques in Regional Anesthesia and Pain Management (2005) 9, 91-96

Sympathetic block: Thoracic and lumbar Ricardo Plancarte-Sánchez, MD, Jorge Guajardo-Rosas, MD, Rocio Guillen-Nuñez, MD From the Department of Pain Clinic and Palliative Care, Instituto Nacional de Cancerologica and Cancerología, Mexico City, Mexico. KEYWORDS: Splanchnic nerves; Celiac plexus; Lumbar sympathetic chain

Since Leriche’s initial reports of pain relief in patients with causalgia and reflex sympathetic dystrophy, the use of sympathetic blocks has become a common interventional technique. Current indications for sympathetic blocks include the diagnosis and treatment of painful neuropathic conditions and certain visceral pain syndromes. In the present article three sympathetic blocks are described including thoracic, splanchnic/celiac and lumbar sympathetic blocks. The thoracic sympathetic block is infrequently selected as a target for treatment because of the risk of pneumothorax, but may be effective for the management of complex regional pain syndrome (CRPS), neuropathic pain, postherpetic neuralgia, thoracic and upper abdominal visceral pain as well as postmastectomy syndrome. The splanchnic and celiac plexus blocks are indicated in the treatment of upper abdominal pain including cancer pain, abdominal angina, hepatobiliary disorders, and acute or chronic pancreatitis. Potential complications with these techniques include hypotension, diarrhea, and visceral injury. Lumbar sympathetic block may be useful in the management of painful neuropathic conditions associated with dysfunction of the sympathetic nervous system or peripheral vascular insufficiency. Like any other major sympathetic block, vasodilation in the vascular bed leading to hypotension may be life threatening and an intravenous access at the time and after the procedure is strongly recommended. In conclusion, when properly performed, sympathetic blockade techniques can be a safe clinical tool for the management of neuropathic and visceral pain conditions when other, less invasive, therapeutic options have failed. © 2005 Elsevier Inc. All rights reserved.

Fundamental considerations Sympathetic block, a commonly used technique in pain clinics, has been suggested to have beneficial effects in cancerous pain. Specific sympathetic blockade is possible at the cervicothoracic level, as the splanchnic nerves and lumbar areas like the celiac and hypogastric plexus. The specific interruption of these areas is possible because the sympathetic ganglia and plexus are anatomically separated from the somatic nerves. It is possible to achieve sympathetic blockade without blocking sensory or motor functions. The lumbar sympathetic block for rest pain of the legs, transdiscal approach for the splanchnic nerves, and celiac plexus block for abdominal visceral pain from cancer, are the most benAddress reprint requests and correspondence: Ricardo PlancarteSanchez, MD, Department of Pain Clinic and Palliative Care, Instituto Nacional de Cancerología, Homero 530-202, Col Polanco, C.P. 11550, Deleg. Miguel Hidalgo México D.F. E-mail address: [email protected]. 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2005.05.008

eficial neural blockade techniques available for thoracic and superior abdominal pain.1 The superior hypogastric plexus blockade and ganglion impar are described in the preceding article of this journal.

Anatomy The peripheral sympathetic nervous system originates in efferent neurons in the intermediolateral column of the spinal cord, passing preganglionic fibers, to the ventral roots from T1 to L2, out of the spinal canal, as the white rami communicants to the sympathetic chain. The sympathetic chain lies at the anterolateral aspect of the vertebral bodies in the cervical region. In the thorax, it is adjacent to the neck of the ribs, relatively close to the somatic nerve roots. In the lumbar region, the sympathetic chain lies anterolateral to the vertebral bodies, and is separated from the somatic nerve roots by the psoas muscle and psoas fascia. The preganglionic fibers run a variable distance within the sympathetic

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chain, to ganglia in the chain, up or down from the segment of the spinal cord where they originate. They may pass to peripherally located ganglia in the gastrointestinal or urogenital tracts. This variable level of relay between the preganglionic and the postganglionic neurons within the sympathetic chain is one reason for variable results from an apparently technically successful block. It is also a reason for regeneration of sympathetic function after a successful sympathetic block and recurrence of the symptoms. There are 12 thoracic ganglia, and 4 or 5 lumbar ganglia. The fibers from the sympathetic ganglion cells are widely distributed to join peripheral nerves via the gray rami communicants, and also join blood vessels of various organs. The sympathetic chain receives efferent preganglionic fibers from the spinal cord as well as efferent visceral fibers carrying pain impulses from the extremities, head, neck, abdominal, and pelvic viscera, including the urogenital system. The carotid arteries, aorta, and vena cava receive direct postganglionic nerves from nearby sympathetic ganglia and plexuses. Sympathetic nerve fibers may arrive at the vessel from adjacent ganglia, via postganglionic fibers passing in somatic nerves to the vessels, and postganglionic fibers that pass up or down the sympathetic chain, or fibers synapsing in the prevertebral plexuses, before they pass to the vessels. All the sympathetic vascular nerves and filaments meet in extensive perivascular and adventitial sympathetic networks. Local anesthetic blockade using perivascular brachial plexus approaches will inhibit sympathetic nervous functions very effectively in the upper extremity. A fact well exploited by continuous brachial plexus block after reimplantation surgery of the extremity.

Thoracic sympathetic block The thoracic sympathetic ganglia are selected infrequently as targets for neural blockade relative to other sites within the sympathetic nervous system. The posterior paravertebral approach was first suggested by Kappis in 1919,2 and is further described by Labat3 and Adriani.4 This approach may be performed at three different levels: blockade of sympathetic chain to the upper limb, to the chest, and to the abdominal viscera.5

Indications Indications for sympathectomies at the thoracic ganglia level are for treatment of CRPS I (reflex sympathetic dystrophy), CRPS II (causalgia), neuropathic pain in thorax, chest wall, thoracic viscera, upper abdominal viscera, herpes zoster, postherpetic neuralgia, and phantom breast pain after mastectomy.6 Other possible indications may include: arterial occlusions leading to ischemia, drug-resistant Raynaud’s disease, Buerger’s disease, and frost injuries of the upper extremities.7 Sympathetic nerve blocks in this area can also provide analgesia of the intrathoracic viscera that may be involved

Figure 1 Thoracic sympathetic block. AP view, contrast agent at the level of T2-T3-T4 in the left side of sympathetic axis.

in neoplastic or other painful processes.8 Neurolytic block of the sympathetic chain from T2 to T8 can be used in patients with severe intractable pain caused by cancer of the esophagus, heart, bronchi, trachea, lung, pleura, or by some other chronic pathologic process of the upper two-thirds of the esophagus.6 Destruction of this chain is indicated for palliation of pain syndromes that have responded to thoracic sympathetic blockade with local anesthetics.7

Technique Identify the point of the entrance at the lateral edge of T2 vertebral body just cephalic to the third rib. A 10-cm needle is introduced and angled toward the vertebral body two fingerbreadths from the midline opposite the T2 spinous process. As the needle is advanced, it either strikes the rib or passes through the intercostal space, and continues until it is held up by the body of the vertebra in the true paravertebral space. The needle is advanced, “hugging” the lateral edge of the T2 vertebral body. A lateral fluoroscopic view confirms the position of the needle in the posterior half of the T2 thoracic vertebral body. An antero/posterior view will demonstrate the needle “hugging” the T2 vertebra at approximately the level of the pedicle. Iohexol 240 dye (approximately 2 mL) is then injected. The dye spread is up and down the thoracic vertebral column. Unilateral placement is confirmed if the spread follows the dome of the lung. If the needle is more lateral than the parietal pleura, it needs to be redirected medially. If this is a diagnostic block, local anes-

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Figure 2 Celiac plexus block approach guided by TC scan, view of the needle tip and the application of air (A) and contrast agent (B) for the “double contrast” technique.

thetic and steroid are injected. Approximately 6 to 8 mL of the mixture is sufficient to block both the T2 and T3 sympathetic ganglia. This can be confirmed by watching the spread of dye before and after injection of local anesthetic. If this is a definitive block, 6% phenol or alcohol may be injected. A successful neuroablation will provide pain relief, and is confirmed if the patient has a warm dry hand and no evidence of Horner=s syndrome (Figure 1).9,10 Another option is the use of radiofrequency neuroablation after successful blockade with local anesthetic; the patient is then scheduled for an RF of the T2 and T3 sympathetic ganglia. The needle (RFK 10-cm needle with a 10-mm active tip) is placed as mentioned above at the T2 sympathetic ganglion. Iohexol dye is injected. Sensory stimulation at 50 Hz and 2V may exert stimulation of intercostal nerves. Before lesioning and after stimulation, local anesthetic and steroids are injected. Thirty seconds is usually enough time to wait before lesioning occurs. Lesioning occurs at 80°C for 90 seconds. When lesioning is complete, the needle hub is directed in a medial– caudal direction. The tip of the RFK needle is curved approximately 15°, and this gives a larger area of burn when rotated, increasing the chance of burning the ganglia. The process is repeated again for the T3 ganglia. At the end of lesioning, the needle is removed. The back is cleansed. A triple antibiotic ointment and bandage are applied over the injection site.11-13

Splanchnic nerves/celiac plexus block Anatomy Preganglionics fibers from the spinal segment T5 to T10 give rise to the lesser splanchnic (T11-T12), greater splanchnic (T5 to T10), and least splanchnic (T12) nerves.

Indications Indications are acute/chronic pancreatitis and hepatobiliary disorder including biliary sphincter disorder, abdominal visceral pain syndrome including cancer pain and abdominal angina.12,13

Technique This technique can be individualized. Different approaches have been used. Percutaneous transcrural approach for the splanchnic nerves/celiac plexus block have

Complications Somatic nerve root injury, spinal cord damage and pneumothorax, are high-risk complications in this procedure.2,7 Another side effect using radiofrequency, is intercostal neuritis. This can be minimized by meticulously performing sensory and motor stimulation before lesioning.14

Figure 3 Splanchnic nerves block. TC scan used, and “double contrast” technique with air and contrast agent.

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Figure 4 Lumbar sympathetic block. Anteroposterior view of the needle seen introduced by the transverse process of L2, and the administration of contrast agent and dissemination to L1.

All patients under sedation and analgesia are placed on the table in decubitus prone position, and previous asepsis, antisepsis of the region of the posterior thorax. With CT scan, a topogram is made with the placement of a needle over the skin, localized at the T10-T11 level. After locating the intervertebral disc at 3 to 7 cm of the middle line in the intercostals left space, the needle is inserted perpendicularly, with a slight inclination toward the middle line, crossing respectively the planes of the paravertebral anatomic area. Then, 8 to 12 mL of phenol is administrated when the tip of the needle is in retromediastinal/retroperitoneal area, after confirming that the contrasted agent and air shows an image of “double contrasted” (Figure 3).15 Following the spread of contrast agent, either local anesthetic agent such as phenol, or alcohol is injected in a volume of 8 to 12 mL for permanent blockade.

Complications been done, including the transvascular, using only one needle, with CT guidance, endoscopically, placing a catheter for intermittent blockade, with ultrasound endoscopy (USE) as guidance, and the transdiscal approach.14 For the celiac plexus block, the posterior approach can be retrocrural, classic, transcrural, or transaortic, where the needle lies in relation to the aorta. With all these approaches, the needles are inserted at the level of the first lumbar vertebra; 5 to 7 cm from the midline, the tip of the needle is directed toward the body of L1 for the retrocrural and anterocrural approaches (Figure 2). All the approaches provide effective sympathetic blockade. The splanchnic blockade is reserved for those patients who have abdominal pathology, such as widespread metastasis of tumor.15 Fluoroscopy or CT scan may be used. USE is used if the patient cannot tolerate the prone position. The needle is directed at the final position in front of the vertebral body. This position is confirmed by both AP and lateral views and the injection of contrast agent, depending on the approach.15

Complications are associated with the technique used. Some complications are hypotension, diarrhea, injury to the kidney, ureter, lung, and pleura (pneumothorax, hemopneumothorax). In all the approaches, paraplegia is a concern because of intrathecal injection or trauma to spinal cord.16,17

Lumbar sympathetic chain block A method of blocking the lumbar sympathetic chain was first described by Mandl in 1926.20 The approach to the chain is similar to that used by Kappis when injecting the celiac plexus, except that the needle is inserted at the level of L3.16 Another approach for the block of lumbar sympathetic chain was described by Bryce-Smith.21 The point for needle entry is the lateral body of the vertebra as it lies within the psoas tunnel.17 Reid and coworkers used a single-needle technique placed at L2.18 Boas and coworkers used a single needle placed at L2 or L3.19

Figure 5 Lumbar sympathetic block. Lateral image shows the needle anterolateral aspect of the vertebral body L2, and the retroperitoneal space identified by spread of contrast agent.

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They used two or three needles at L2, L3, and L4, placed in the center of the vertebral body. However, in patients with cancer, where the anatomy is modified, for progression of the tumor, lymphatic congestion, or fibrosis postradiotherapy, it is preferable to make a bilateral boarding at one or two levels.

Indications Indications for lumbar sympathetic blockade include: diagnosis, prognosis, and therapy for pain and other conditions presumably associated with a dysfunction of the sympathetic nervous system. These include: complex regional pain syndrome types I and II, herpes zoster, amputation stump pain,20 inoperable peripheral vascular and vasospastic diseases of the lower extremities. Other indications include selected cases of pelvic pain in which superior hypogastric nerve block cannot be performed.21

Technique Two techniques are described: the classical technique22 and lateral approach.23 Classical technique Classical approach of the spinous processes at L-2, L-3, and L-4 are identified. Skin wheals are raised 4 cm lateral to these spinous processes. Starting at L-2, a 22-gauge spinal needle is used to infiltrate a track of local anesthetic between the skin and transverse process. The needle is then “walked off” the inferior border, and advanced until it contacts the body of the vertebra. The same procedure is repeated for the other two needles at L-3 and L-4. The image intensifier should be used to verify the depth and relationship of each needle to the vertebral bodies. Both AP and lateral projections must be used. If the position of each needle is satisfactory, it is in turn redirected to pass lateral to the vertebral body. A small 2-mL syringe full of air is attached, and the loss-ofresistance test is performed, while the needle is advanced through the body of the psoas muscle. As soon as the needle tip escapes the muscle, a positive test should identify the plane in which the sympathetic chain is lying. With each needle tip observed from lateral projection of the large intensifier, a small amount of radiopaque material is injected through each needle. Confirmation can be made whether or not the injection has been made into the correct retroperitoneal place. Both AP and lateral projections are necessary to ensure a correct depth of the needle, its lateral relationship to the vertebral body, and the correct spread of injectated through each needle (Figures 4 and 5).15,24,26 Lateral technique With the patient in prone position, the operator, under fluoroscopy and avoiding the transverse process of L2 or L4, inserts a 5-inch spinal needle. The tip of the needle is in front, and just lateral to the L2 vertebra, or at the superior third of the L3 vertebra where the sympathetic ganglion is located.

95 On both AP and lateral views, injection of contrast agent confirms the spread in front of, and lateral to, the vertebral body. Then 10 mL of 1% lidocaine or 1% mepivacaine is injected. If a more prolonged block is desired, 0.5% bupivacaine may be used. Once a diagnostic block has shown symptomatic relief, a neurolytic solution is indicated for therapy. When a semipermanent block is to be used in the treatment of intractable pain from cancer, anticancer (surgery, chemotherapy, radiotherapy) or vascular insufficiency, phenol, either 6% in water or 10% in glycerin, is satisfactory. The volume of the neurolytic solution is of 5 to 6 mL for each needle. Remember that the patient with cancer has altered regional anatomy. Hence, it is recommended to use the bilateral approach for best results. Finally, the needle is flushed with 1 to 2 mL of normal saline or local anesthetic before it is withdrawn.15,26-28

Complications Complications may include: infection, injury of spinal cord or somatic nerve, kidney trauma, hypotension, paraplegia, and genitofemoral neuralgia.15,25

General cautions A nerve block close to the central neural axis may also produce a sympathetic block producing vasodilatation in the vascular beds, distal to the block, resulting in hypotension. Unless contraindicated for medical reasons, patients should be encouraged to increase their fluid intake for several days preceding the block. In addition, for major blocks (stellate, celiac, lumbar, and hypogastric plexus), patients are advised to consume a clear liquid diet the day of the block. Venous access is strongly advised, allowing additional prehydration dose of 500 to 1000 mL of balanced salt solution at the time of the block. Patients should arrive with a companion who can remain with them and assure safe transport home.

References 1. Breivik H: Sympathetic blocks, in Breivik H (ed): Clinical Pain Management: Practical Applications and Procedures. Great Britain, Arnold, 2003, pp 233-246 2. Kappis M: Sensibilitt und local ansthesie in chirurgischen gebiet der bauchhole mit besonderen bercksichtigung der splanchnichusansthesie. Bruns Beitr Klin Cher 15:161, 1919 3. Labat G: Paravertebral dorsal block: blocking of the dorsal or thoracic nerves, in Labat G (ed): Regional Anesthesia: Its Technique and Clinical Application (ed 1). Philadelphia, PA, WB Saunders Co., 1924 4. Adrini J: Thoracic sympathetic block, in Adriani J (ed): Nerve Blocks: A Manual of Regional Anesthesia for Practitioners of Medicine (ed 1). Chicago, Illinois, Charles C. Thomas Publisher, 1954 5. Bonica JJ, Bucley PF, Morica G, et al: Neurolytic blockade and hypophysectomy, in Bonica JJ, Loeser DJ, Chapman RC, et al (eds): The Management of Pain (ed 2). Philadelphia, PA, Lea & Febiger, 1990 6. Waldman SD: Thoracic sympathetic ganglion block, in Waldman SD (ed): Interventional Pain Management. Philadelphia, PA, Saunders, 2001, pp 399-400 7. Roos DB: Sympathectomy for the upper extremities: anatomy, indications and techniques, in Rutherford R (ed): Vascular Surgery. Philadelphia, PA, WB Saunders, 1977

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8. Stanton-Hicks M, Stephen EA, Nolte H: Sympathetic blocks, in Raj PP (ed): Practical Management of Pain (ed 1). Chicago, IL, Year Book Medical Publishers, 1986 9. Roos DB: Sympathectomy for the upper extremities: anatomy, indications and techniques, in Rutherford R (ed): Vascular Surgery. Philadelphia, PA, WB Saunders, 1977 10. Breivick H, Cousins M, Bertil Lofstrom J: Sympathetic neural blockade of upper and lower extremity, in Cousins MJ (ed): Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA, Lippincot-Raven Publishers, 1998, pp 411-445 11. Wilkinson H: Percutaneous radiofrequency upper thoracic sympathectomy: a new technique. Neurosurgery 15:811-814, 1984 12. Elias M: Sympathetic blockade, in Wallace M (ed): Pain Medicine and Management. New York, NY, McGraw Hill, 2005, pp 344-348 13. Waldman S, Patt R: Celiac plexus block, in Waldman SD (ed): Interventional Pain Management. Philadelphia, PA, Saunders, 2001, pp 493-507 14. De Medicis E, De Leon-Casasola O: Neurolytic blocks, in Breivik H (ed): Clinical Pain Management: Practical Applications and Procedures. Great Britain, Arnold, 2003, pp 247-254 15. Plancarte SR, Mayer RF, Guillen NR, et al: Abordaje transdiscal de nervios esplacnicos. Cir Ciruj 71:192-203, 2003 16. Macintosh R, Bryce-Smith R: Lumbar sympathetic chain block, in Macintosh R, Bryce-Smith R (eds): Local Analgesia Abdominal Surgery. Edinburgh, Livingstone LTD, 1962

17. Bryce-Smith R: Injection of the lumbar sympathetic chain. Anesthesia 6:150, 1951 18. Reid W, Watt JK, Gray TG: Phenol injection of the sympathetic chain. Br J Surg 57:45, 1970 19. Boas RA: Sympathetic blocks in clinical practics. Int Anesthesiol Clin 16:149, 1978 20. Cousins MJ, Reeve TS, Glynn CJ, et al: Neurolytic lumbar sympathetic blockade: duration of denervation and relief of rest pain. Anaesth Intensive Care 7:121-135, 1979 21. Mekhail N, Malak O: Lumbar sympathetic blockade. Tech Reg Anesth Pain Manag 3:344-345, 2001 22. Mandl F: Die Paravertebrale Injection. Vienna, J Springer, 1926 23. Reid W, Watt JK, Gray TG: Phenol injection of the sympathetic chain. Br J Surg 57:45, 1970 24. Stanton Hicks M: Lumbar sympathetic nerve block and neurolysis, in Waldman SD (ed): Interventional Pain Management. Philadelphia, PA, Saunders, 2001, pp 485-492 25. Mekhail N, Malak O: Lumbar sympathetic blockade. Tech Reg Anesth Pain Manag 3:345-348, 2001 26. Mandl F: Die paravertebrale injection. Vienna, J Springer, 1926 27. Reid W, Watt JK, Gray TG: Phenol injection of the sympathetic Chain. Br J Surg 57:45, 1970 28. Stanton Hicks M: Lumbar sympathetic nerve block and neurolisis, in Waldman SD (ed): Interventional Pain Management. Philadelphia, PA, Saunders, 2001, pp 485-492